When I joined in the historical article challenge from skullsinthestars, my first thought was that I wanted to write on Phineas Gage. Alas, for I am but a young science blogger, and I should have known better. Phineas Gage is, after all, one of the most famous patients in all of medicine, and one of the founding cases of neurology and modern behavioral neuroscience. So there are many bloggers, most far better than I, who have been there before me (for instance there’s an excellent post over at neurophilosophy, as well as one at Restrospectable). Phineas Gage is even known in the modern media, and was mentioned in a recent episode of In Our Time, and is of course covered in every Intro Psychology class in college. So for the challenge, I’m doing something else, and it will happen (and has to happen soon! I didn’t realize the deadline was so close!).

But I couldn’t just let the post on Phineas Gage go. After all, I dug ALL those old articles out of the stacks, and read a 40 page gag-inducing review on the effects of the case on phrenology. So I’m doing a post on Phineas Gage anyway, just to try my hand at it, and because it’s awfully cool. Links to related sources where I can find them, but it’s stunningly hard to find internet references to things that happened in the 19th century. If anyone sees something I haven’t cited and knows where it is, please let me know! I will gladly cite you as well as my detective. 🙂

When I ask people if they know who Phineas Gage is, most people stop and say “who?” Then you say five words “railroad spike through the head”, and everyone says “OH! YES!” The case of Phineas Gage is one of the best-known case reports in medicine, and since then, Phineas Gage and his tamping iron have been the source of numerous books, TV specials, retroactive research, review articles, and neurology lectures. This is pretty good fame for a railroad foreman whose only claim to fame was a freak accident.

Phineas P. Gage was a railroad foreman from Lebanon, NH, who most sources think was born in 1823 (Harlow, 1868). He was literate (railroad foremen at the time had to keep “time-books” that required them to write), but probably never made it past about the 5th grade level. He went to work for the R & B Railroad in Cavendish, VT, in about 1847, and he soon became the foreman of a crew responsible for blowing out rock prior to laying down new track. A procedure called “tamping” is used to set an explosive charge in a hole and exploding the charge to loosen the rock below.

How to Tamp an Explosive Charge1) First, drill a hole into the rock.
2) Fill the bottom of the hole with gunpowder.
3) Add a fuse that comes out of the hole.
4) Then pour sand on top of the gunpowder. The sand serves to absorb upward force from the explosion and keep most of the explosion down toward the rock.
5) Take a heavy iron (a tamping iron), and thwack the sand down nice and firm.
6) Light the fuse and stand back.

Obviously, this doesn’t sound like the safest procedure, but Phineas Gage was probably very used to it by the time the accident occurred.

So what is a tamping iron? A tamping iron is any kind of heavy iron used to tamp down the charge. Many people used crowbars, but Phineas Gage, being the foreman of his group, had a tamping iron commissioned for him. It was 3’7”, 1.25” wide at the thick end, and tapered gradually over the last foot of the iron to a point of 0.25” wide at the other. It weighed (weighs, actually, it’s still around, and is on display in the Warran Anatomical Medical Museum at Harvard) 13.25 lbs (MacMillan, 1986). So this thing wasn’t something light that was just being thrown around. And here’s how it got in his head (All of the quotes and medical accounts below can be found in the original publication, Harlow, 1848).

On the afternoon of Sept 13th, 1848, Phineas Gage was with his men laying charges. Apparently he poured in the gunpowder, and was tamping it slightly before pouring in the sand. It is possible the other man that he was working with was supposed to pour in the sand and didn’t do it in time, or that Phineas Gage tamped the gunpowder himself on purpose. Either way, he turned his head to look at his other men on his right. When he dropped the tamping iron down again, it struck both the rock of the hole and the gunpowder, igniting a spark that set off the charge.

Dr. John Harlow, the doctor who treated Gage, describes what happened next: it [the iron] penetrated the integuments, the masseter and temporal muscles, passed under the zygomatic arch, and (probably) fracturing the temporal portion of the sphenoid bone, and the floor of the orbit of the left eye, entered the cranium, passing through the anterior left lobe of the cerebrum, and made its exit through the median line…breaking up considerable portions of brain, and protruding the globe of the left eye from its socket by nearly one half its diameter.”

Most people imagine that the iron remained in Phineas’ head, and most pictures trying to explain the accident do put an iron in situ (see above, from the anthropology department at Mesa College). But the force of the explosion actually drove the iron all the way through the head, and in fact the iron then flew through the air and landed 30 meters away, “all blood and brains.”

Amazingly, Gage may never have even lost consciousness! He was thrown back on the ground, and apparently convulsed and was stunned, but was talking in a few minutes, and was capable of sitting up in the cart that carried him ¾ of a mile back to his lodgings. He was even able to walk without much help.

Dr. Harlow came to see Gage about two hours later, and if you don’t like blood and guts, I wouldn’t read on from here if I were you. Dr. Harlow describes the scene as “to one unaccustomed to military surgery, truly terrific”, the patient was bleeding both internally and externally, and vomiting blood every 15-20 minutes. Dr. Harlow and his friend Dr. Williams dressed the wound, and in the process “I passed in [to the wound] the index finger its whole length, without the least resistance, in the direction of the sound of the check, which received the other finger in like manner.” The tamping iron had left a hole all the way through the head that was 3.5” across. The two doctors then pulled out several fractured pieces of bone, cut off a portion of the brain that had been left hanging, and replaced the larger pieces of skull. They did not sew the wounds on the top of the head and the cheek closed, but left them open to drain.

Aside from the massive hole in his head, the heat of the explosion had also burned his hands and arms all the way to the elbows. However, during the entire procedure of pulling out bits of bone and brain and dressing his wounds and trying to stop the bleeding, Gage remained conscious and under no anesthesia for the pain. He recognized Dr. Harlow and said that he “hoped he was not much hurt.” Amazingly, by the second day after the accident, he could see things indistinctly with his left eye (the one that had been pushed halfway out of its socket). But by the third day, the wound in his head had become infected, and he became fevered and delirious, and remained very sick until the 3rd of October. Dr. Harlow prescribed conventional medications at the time, which meant purgatives, though he didn’t bleed him (which was a good thing, Gage had lost more than enough blood by then).

During the time he was “semi-comatose”, he formed an abscess under the frontalis muscle, the muscle right next to the hole in the head. When they punctured it, they got nearly 240 mL of fluid out. Had they closed up the wound in the first place and sutured the skin closed, the abscess probably would have gone unnoticed. Most of the literature about cases around 1868 shows that Dr. Harlow’s cleanliness (re-dressing the wounds and allowing things to drain, using nitrate of silver, which has antiseptic properties), was well ahead of his time, and were probably what allowed Gage to heal so well.

And he did heal. Most people who have heard of the case now seem to think he probably only lived a few days or weeks after the accident, but in fact he was up and walking a month after the injury, and lived for 12 years afterward, carrying his famous tamping iron wherever he went, and dying from complications of seizures in San Fransisco in 1861. That was part of what made the case so amazing. Until the case of Phineas Gage (and a few others), doctors firmly believed “that the slightest injury of the brain was followed in all cases by death” (Wharton, 1818, from Macmillan, 1986), even though stories of recovery from destruction of brain areas had been heard of since 1793. There are even more cases which followed after the case of Phineas Gage, for example the case of Lewis Avery (Noyes, 1882), who’s musket exploded in his face in 1881. The breech pin had been driven through the skull above the right eye and stuck in the frontal lobe. Avery in fact didn’t even know the pin was there until 1882, when he was trying to get his facial disfiguration repaired, and the breech pin was discovered.

Even though there have been many cases of dramatic brain loss from the 18th and 19th centuries (such as Noyes, 1882, Jewett, 1868, or Armour, 1831) it was the case of Phineas Gage that became the standard by which other brain injuries were judged. More important, the effects of Gage’s injury had a strong impact on the medical world, even though the findings were not published until 1868, after Gage’s death (Harlow, 1868).

Dr. John Harlow’s case study “The passage of an iron rod through the head” published in the Boston Medical and Surgical Journal in 1848, garnered skepticism, criticism, and complete disbelief by most of the medical community in the first few years after its publication. In fact, there are only five references to the findings, all of them using descriptors such as “remarkable”, “wonderful”, and “extraordinary” (MacMillan, 1986). Many medical experts did not believe the iron rod passed through the skull at all, and only began to believe it when Dr. Harlow had Phineas Gage attend the Boston Society for Medical Improvement in 1850, where doctors could examine him and trace the path of the iron rod themselves (Bigelow, 1850).

To all appearances, Gage made a full recovery. Even in the first hour after the accident, he was able to recount what happened, recognized people he knew, and remembered who he was and where he lived. Dr. Harlow examined him about a month later, and he remembered exactly when he had been injured. He could not estimate size or money accurately, possibly because with one eye out of commission he was having trouble differentiating depth or size.

But something had clearly changed. Even in his first report Dr. Harlow describes Gage after the accident as being “very childish”, and “uncontrollable by his friends.” In his later psychological case study, Dr. Harlow (1868) noted that Gage was unable to get his former job back. Where before he had been loved by his men and considered “efficient and capable” by his contractors, he was now described as “fitful, irreverent, indulging at times in the grosses profanity (which was obviously considered much worse back then),…capricious and vacillating…his mind was radically changes, so decidedly that his friends and acquaintances said he was ‘no longer Gage’.”

The case of Phineas Gage was the first one to give rise to the idea that certain parts of the brain could be responsible for personality and social behavior. Although the case received limited attention at the time, it became a signature case for behavioral syndromes resulting from frontal lobe dysfunction (Neylan, 1999). Subsequent studies and remodeling of the skull and the path of the tamping iron have been done, and these studies, coupled with modern studies of other patients with frontal damage, have shown that the ventromedial frontal region of the brain is partially responsible for processing emotions and making rational social decisions (Damasio, 1994).

This is a very thought of report… nice details and narrative. I am also writting a paper on gage and cannot for the life of me find the 1868 report from John Harlow – when I click on ur link it takes me to a database with different information. – would you share how you got to the 1868 report?